HomeMy WebLinkAboutLITTLE BEAR BLK 1 LT 76
L~
~Z
Z
PERMIT NO.
FIPF'L. I CRN"I'
I..OCFI'I' ~ ON
I..EGRL
E:Zo.:LO WEL, L_E;LE'-r' C*l'
L. CFI" 51 ZE
H Zi',,I]:HUI~I [:,ISTRI'.,ICE BETWEEN FI WELL RND FIl'4h,' ON.-.SIl% 5;EWFIGE
:LOO F:E:ET FOR R PR :i[ 'v'FITE WEI..L. OF,' ;288 FEET FOF.". t::~ PUBLIC 1,4EI_.,L.
IqE:L.L. LOGS FIRE RErZJ'[RED FIND i','IUST BIE RETtJF..'NED TO THE DEPFIR"f'HENT I.,.I~Tt4]:t'.~
OF THE t4ELL COI"IPLETION.
:i.-.iP[E[:: % F :il: CRT 1_:' ONS FIND C'ONSTRUCT I ON [) I RC~iRRI"I5 I:'I[;.'.E FIVFI :[ L.RBL. E TO
:r. NSTRLLRT 1' ON,
I CEF.:TIF"r' THRT
Z: I RH FRMILIRR ,t4I"f'H THE RE':QUIREMEI",ITS FOR ON-SITE E;IE!4ERr'.S FIN[:, [,IELI...S; Pi:S 'SET
F'ORTH B"r' THE I'IUNICIPRLIT"r' OF RNCHORFIGE.
,.~:. I WILL, INS;,TFILL THE :,'r:,l'El"l II',1 I::ICCOF.:DRNCE 1.4ITFI THE
'" T Gl' lET'" ~
FIF'PL I C:FINT E:D I;'. I I'-~NE F.:
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date A-?,-~ / M'7.` I'~g 7
GENERAL INFORMATION
(b)
(c)
Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
Applicant Name ~¢~q~ (¢[(~¢ Telephone: Home
Applicant Address ~¢~/ ~6Z ~
Applicant is (check one): Lending Institution ~; Owner/~uilder ~; Buyer ~; Other ~ (explain);
Business
(d) Lending Institution ,~o r./~/~t~ 0/,.. h'for' ~,¢t~,¢_. Telephone ~¢ ~ -~¢
Address ~00 ~. ~or ~ ~or~.. ~ ~
(e) Real Estate Company and Agent N~ ~, (R~c~)
Address
Telephone
(f) Mail the HAA to the following address:
TYPE OF RESIDENCE
Single-Family[] Multi-Family []
Number of Bedrooms 3
Other
WATER SUPPLY
Individual Well [] Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
SEWAGE DISPOSAL
Onsite [] Public [] Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
Page 1 of 2 72-025 (11,84)
'~tJOM s,Jeeu!bue leUO!SS@J, oJd
8q~ u] SUO!$S!LUO ,lO S JO J J@ JO,t elq!suodseJ lou s! eSeJOqOUV Jo &!led!o!unlgl eq.l. 'panss! s! m, eou!lJoo e @JO,teq e~ep ez,qeue
Jo suo!~oedsu! ~onpuo3 ~ou op d3HCI ,to see/[OldUJ=J 's~ueLueJ!nbeJ e~els pue leJapej u!~peo Als!les oh JepJo u! suoBn~!~,su!
8u!puel J!@q~ puc SeLUOq ,tO sJ@seqoJnd ol Asel~noo e se s!ql s@op cl3HG eq/ 'e>tSel¥ jo e~elS eqi u! peJ@lS!SeJ Jeeu!Sue
leUO!SSe~OJd ~u@puedepu! ue Aq e^oqe g qdm§med u! ue^!8 suoce~u@seJdeJ @q~ uodn ,(lalOS peseq se~eOgilJeO le^oJddv
A~poq~n¥ q~leeH senss! (d3HCI) uo!loe~OJd le~UeUJUOJ!^U3 pue q~leeH ,to ~ueculJedecl eSmoqou¥ jo ,q!led!ounlAI eq_L
NOl~n¥o
leAoJdd¥ leUO!l!puoo ,to swJe/
leUO!l!puoo poAoJddes!a -~,~ pe^oJddV
..... Xq SLUOOJpoq (¢ r//~¢'/~. JO~ poAoJddv
'9
.g
WELL DATA
MUNICIPALITY OF ANCHORAGE (MOA)
(] ] Ai ] AUT.OR,TY APP.OVAL
~"~ CHECKLIST - FEBRUARY 1984
264-4720
Lr 6[ Udv
('~-'7~,.~ Legal Description: /'" c~ 1~
NOi$1AiO'~J~DiA~i~t~iViN~WNO~IIAN~ /.- I~¢' I~ ~ ~ /
~O~OHgNV ~0
Well Classification
Well Log Present (Y/N) _
Total Depth ¢'O '
Static Water Level .
Casing Height Above Ground
Pm'~'~'~"~ If A, B; C, D.E.C. Approved (Y/N)
~ Date Completed _[ ¢--- ,/E.~ ,/7 ¢ Yield
Cased to ~ ' Depth of Grouting
¥* Pump Set At
~ 'f" Sanitary Seal on Casing (Y/N)
Electrical Wiring in Conduit (Y/N) _ ~
Separation Distances from Well:
To Septic/Holding Tank on Lot t'4.~. (74f,/~¢
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
Cleanout/Manhole
Water Sample Collected by
Water Sample Test Results
Comments $ -/'",~,~ ~
Depression Around Wellhead (Y/N) t¢
~"¢~' """ ) ; On Adjoining Lots
; On Adjoining Lots
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
; Date
B, SEPTIC/HOLDING'rANK DATA
Date Installed
Standpipes (Y/N) Air-tight Caps (Y/N)
Depression over Tank (Y/N)
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well
To Property Line
To Water Main/Service Line
Course
Size No. of Compartments
Foundation Cleanout (Y/N)
Date Last Pumped
; for
Temporary Holding Tank Permit (Y/N)
To Building Foundation
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
Page 1 of 2
72-026(11/84)
C. ABSORPTION FIELD DATA ~. ,4. ~ ?~/~ t'~ ~'~' ~'"}
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well
To Building Foundation
Lot
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Standpipes Present (Y/N)
Date of Last Adequacy Test
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots
To Cutbank (if present)
D. LIFT STATION N,A',
Date installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed ~'~ ~--'~ Date
Company F[~/'/~? '1-~¢/~ ~ MOA No.
ReceiptNo. ~ ~ ~ ~/~OO'~ 7
Date of Payment ~/¢~ ¢ 7
Amount: $ /O ¢ ,~~,~:...'~ ~ ~" ...... A ,,~:]c~,.~,~r¢~, Engineer's Seal
Page 2 of 2
72-026 (11/84)
I Telephone 264-4720 AR
~l~[~?lO~g: Oompl~te ~11 parts on pa~ 1. In~omploto r~sB ~ill not bo pro~,ss~d. Please allow ~n {10} davs for prooessin~.
MAIEING ADDRESS ·
PROPERT~ R~SIDEN~ (Ifd[}ferCnt__~~from abGve}~ ~ PHONE
2, BUYER ~ PHONE
MAILING ADDRESS
LENDING INSTITUTIO~ "
MAI LIN~ACDR~SS ~/ , ~ .
SB, LEGAL DESCRIPTION
TREE'r, LOCATI,I~'N ' - ' / - -' ' .~ - - - ' ~- ¢ '
6, TYPE OF RESIDENCE R~ ~"'L I I ----,,~ NUMBER OFBEDROO~IS
~ S INGLEFAMILY ~-v~g/f~j /YIY4P' [~] ?nwe° [-J FF~,Uer [] Other
[] MULTIPLE FAMILY ~ Three [] Six
7, WATER SUPPLY
~ INDIVIDUAL*
[] COMMUNITY
[] PUBLIC UTILITY
8, SEWAGE DISPOSAL SYSTEM
[]' INDIV DUAL/ON.SITE'~
~ PUBLIC'UTILITY
ATTACH WELL LOG. A well Icg is required for all wells drilled
since June 1975. For wells drilled prior to that date, give well
depth (attach Icg if available.)
**If individual/on-site, give installation date
If system is over two (2} years old an adequacy test ~s required
by this Department.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROC ESSING CAN BE INITIATED,
72-010(3/78)
THIS SIDE FOR OFFICIAL USE ONLY .:..
DATE RECEIVED
INSPECTION APPOINTMENTS
TIME TIME TIME
DATE DATE DATE
INSPECTOR INSPECTOR iNSPECTOR
DIRECTIONS:
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] SINGLE FAMILY [] ONE ~ THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
PERMIT NUMBER
2. WATER SUPPLY
~ INDIVIDUAL DEPTH OF WELL
[] COMMUNITY DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED/j,_%,~ ~) ~ \o_~L~ ~------~, ~ .
3, SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[] INDIVIDUAL/ON -SITE DATE INSTALLED
'1~] PUBLIC UTILITY
Connection Verified INSTALLER
[]Septic Tank or [] Holding Tank
Size: If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCESwELL TO: Septic/Holding Tank IAbsorption Area Sewer Line I Nearest Lot Line
Absorption Area to nearest Lot Line
5. COMMENTS
E3~]/APPROV ED FORL-':'~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
DATE B~
LEGAL DESCRIPTION
72-010 (Rev. 3/78)
~ ~ GREATER ANCHORAGE AREA BOROUGH
Department of Environmental Quality
~ 3330 "C" Street, Anchorage, Alaska 99503 274-4561
~) ~ Date Received January 11, 1977
l. Approval requested by: Amfac Mortgage
Mailing Address: 705 West 6th Avenue Phone: 277-8588
2. Property Owner: Lawrence Sebring Phone: 344-7474
Mailing Address: 4041 Truro
3. Legal Description: Lot 7 Block 1 Little Bear Subdivision
4. Location: Baby Bear Place, off of East 68th Avenue
5. Type of facility to be inspected Single Family No. of bedrooms 3
6. Well Data: Permit ~76308 ~/~(~ ~'~
A. Type ~/<~l~$b~ B. Depth ?0]
C. Construction ~-~1/~,~_~~ D. Bacterial Analysis ~-' ,
7. Sewage Disposal System:
A. Installed Public B. Installer
C. Septic Tank: 1. Size 2. Manufacturer
D. Seepage Pit: 1. Absorption Area 2. Material
E. Disposal Field: Total length of lines
8. Distances:
A. Well to: Septic tank , Absorption area , Sewer Lines ,
Nearest lot line , Other contamination
B. Foundation to septic tank , Absorption area
C. Absorption area to nearest lot line
EQ-034 (1/74) Page 1 of two pages
Page 2 of two pages - Re¢ st for Approval of Individual S }r &'Water Facilities
Legal Description Lot 7 Block 1 Little Bear Subdivision
Comments
APproved~~~~ Disapproved Date /~'~//
Approve/Valid for one year from date signed
Greater Anchorage ~ea Borough, Department of Environmental Quality
DIAGRAM OF SYSTEM
I certify that the information contained in this request for approval to be a true and
accurate representation of the subject sewer and water facilities and these facilities
are operating satisfactorily,
SIGNED
Date
EQ-034 (1/74)
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION {3P..J~;, (~ NEALTH &
2510 East Tudor Road, Anchorage, Alaska 99504 276-2221
3. Name of Buyer:
Mailing Address: ~
4. Name of Lending Institution:
Mailing Address:
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER and WATER FACILITIES
Type of Inspection: CMRO VA FHA
Property Owner: Z ~c~ ~"~ ¢'~-' C~-- ~'~---~e/~ ~ ~'~ ~f,-~
Mailing Address.. z~ y~ y~ ~'¢-,¢,,'E0 ~/'~"~a;?~h~o2ne:
JAN t t ~77
REC£1 . D
CONV.
Day Phone:
,~ ~3. ~2-~,~_~_, Phone:
Name of Realtor or Agent: ~1 ~ ~ ~ ~/~
Mailing Address: ~/~ ~/~ ~'~ Phone:
Legal Description: ~ ~ ~/~ / ~ ,'~
7. Type of Facility to be Inspected:
No. Bdrms. ,-~
Water Supply
Type of Supply: Public Utility
If Individual, number of dwellings presently served
If Individual, depth of well °~ !
(~individual
/
Sewage Disposal System
Type
of System: ~ity,. _
If Individual, date of installation
Individual (on-site)
72-003(3/76)